A comprehensive survey of Canadian hematologists has uncovered significant variations in supportive care strategies for elderly patients with myelodysplastic syndromes (MDS) and acute myeloid leukemia (AML) receiving less intensive therapy. The study, published in Annals of Hematology, reveals crucial gaps in standardized care approaches and emphasizes the urgent need for evidence-based guidelines.
Current Transfusion Practices and TXA Usage
The survey, which gathered responses from 105 hematologists primarily working in academic or tertiary care settings (92%), found nearly universal adoption of prophylactic platelet transfusions (95%). However, significant variation exists in the use of tranexamic acid (TXA), with only 57% of respondents incorporating it into their prophylactic strategy.
Among those utilizing platelet transfusions, 83% implement a transfusion threshold of < 10 × 109/L for afebrile outpatients with MDS/AML. Notably, 87% of respondents indicated they would proceed with platelet transfusions regardless of the patient's active chemotherapy status.
Barriers to TXA Implementation
Several key factors influence the limited adoption of TXA in clinical practice:
- 54% cited uncertainty about benefits and potential risks
- 30% expressed concerns regarding venous thromboembolism (VTE)
- 28% identified cost as a limiting factor
The majority of practitioners consider gross hematuria (87%) and active VTE (65%) as contraindications to TXA administration.
Antimicrobial Prophylaxis Patterns
The survey revealed diverse approaches to infection prevention, particularly noteworthy given that infection remains a leading cause of morbidity and mortality in this patient population. Key findings include:
- 69% of hematologists do not prescribe prophylactic antimicrobials for patients receiving best supportive care without active chemotherapy
- Fluoroquinolones emerged as the most commonly prescribed antibacterials (90%)
- Among antifungals, fluconazole (66%) and voriconazole (36%) were preferentially selected
Challenges in Antimicrobial Prophylaxis
Respondents identified several barriers to implementing antimicrobial prophylaxis:
- 70% cited insufficient evidence
- 60% expressed concerns about antimicrobial resistance
- 50% worried about risks such as Clostridioides difficile infections
Future Directions
The survey results underscore the pressing need for robust clinical evidence to guide supportive care decisions. An overwhelming majority of respondents (94%) endorsed the need for clinical trials to evaluate optimal prophylactic strategies, particularly in areas where current practice shows the greatest variability.
As the aging population leads to increased incidence of MDS and AML, the development of standardized, evidence-based guidelines becomes increasingly critical. The survey findings will serve as a valuable foundation for designing future clinical trials to assess the benefits and risks of various prophylactic approaches in this vulnerable patient population.
